Provider Demographics
NPI:1508996141
Name:BONILLA, MARIA LOPEZ (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LOPEZ
Last Name:BONILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 GENESEE AVE
Mailing Address - Street 2:SUITE 460
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1224
Mailing Address - Country:US
Mailing Address - Phone:858-362-8800
Mailing Address - Fax:858-362-8803
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:SUITE 460
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-362-8800
Practice Address - Fax:858-362-8803
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2021-12-03
Deactivation Date:2013-04-15
Deactivation Code:
Reactivation Date:2013-11-27
Provider Licenses
StateLicense IDTaxonomies
CAA105637207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology